Cancer Association of South Africa (CANSA)

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Cancer Assciatin f Suth Africa (CANSA) Fact Sheet and Psitin Statement n the Ketgenic Diet Intrductin Dieting is the practice f eating fd in a regulated and supervised fashin t decrease, maintain, r

[Picture Credit: Ketgenic Diet] A study published in the American Psychlgical Assciatin s jurnal American Psychlgist fund that dieting alne des "nt lead t sustained weight lss r health benefits fr

1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet and Psitin Statement n the Ketgenic Diet Intrductin Dieting is the practice f eating fd in a regulated and supervised fashin t decrease, maintain, r increase bdy weight. Dieting is ften used in cmbinatin with physical exercise t lse weight, cmmnly in thse wh are verweight r bese. [Picture Credit: Ketgenic Diet] A study published in the American Psychlgical Assciatin s jurnal American Psychlgist fund that dieting alne des "nt lead t sustained weight lss r health benefits fr the majrity f peple. Hwever, ther studies have fund that the average individual maintains sme weight lss after dieting. Weight lss by dieting, while f benefit t thse classified as unhealthy, may slightly increase the mrtality rate fr individuals wh are therwise healthy. (Wikipedia). The Ketgenic Diet The ketgenic diet is a specific high-fat, lw-carbhydrate diet that helps t cntrl seizures in sme children with epilepsy. It is prescribed by a physician and carefully mnitred by a Registered Dietitian. The Ketgenic Diet requires careful measurement f kiljules, fluids, and prteins. The name ketgenic means that it prduces ketnes in the bdy (ket = ketne, genic = prducing). Ketnes are frmed when the bdy uses fat fr its surce f energy instead f carbhydrates. Usually the bdy uses carbhydrates (such as fruit; cereals such as ats; starchy vegetables such as ptates, sweet ptates, butternut, rice and pasta) fr its fuel, but because the ketgenic diet is very lw in carbhydrates, fats becme the primary fuel instead. Ketnes are nt necessarily dangerus. They can be detected in the urine, bld, and breath. Ketnes are ne f the mre likely mechanisms f actin f the diet; with higher ketne levels ften leading t imprved seizure cntrl. Hwever, there are many ther theries fr why the diet will wrk (Epilepsy Fundatin). April 2017 Page 1

2 Ketsis Ketsis is a wrd ne will mst prbably see when lking fr infrmatin n diabetes r weight lss. It is a nrmal metablic prcess, smething ne s bdy des t keep wrking. When the bdy des nt have enugh carbhydrates frm fd fr ne s cells t burn fr energy, it burns fat instead. As part f this prcess, ketnes are frmed. If ne is healthy and eating a balanced diet, ne s bdy cntrls hw much fat it burns, and ne will nrmally nt make r use ketnes. But when ne cuts way back n kiljules r carbhydrates, like ging n a high-fat-lw-carbhydrate diet, ne s bdy will switch t ketsis fr energy. It can als happen after exercising fr a lng time and during pregnancy. Fr peple with uncntrlled diabetes, ketsis is a sign f nt using enugh insulin. Ketsis can becme dangerus when ketnes build up. High levels f ketnes lead t dehydratin and changes in the chemical balance f ne s bld. In ketsis the patient s breath and urine usually smells like acetne. (WebMD; Diabetes Frums). There is ften cnfusin as t the difference between ketsis and ketacidsis. Ketsis is the state whereby the bdy is prducing ketnes. In ketsis, the level f ketnes in the bld can be anything between nrmal t very high. Diabetic ketacidsis, als knwn as DKA, nly describes the state in which the level f ketnes is either high r very high as a result f diabetes. In ketacidsis, the amunt f ketnes in the bld is sufficient t turn the bld acidic, which is a dangerus medical state. Ketsis will take place when the bdy needs energy and there is nt sufficient glucse available fr the bdy. This can typically happen when the bdy is lacking insulin and bld glucse levels becme high. Other causes can be the result f being n a lw carbhydrate diet. A lw level f carbhydrates will lead t lw levels f insulin being prduced, and, therefre, the bdy will prduce ketnes which d nt rely n insulin t get int and fuel the bdy s cells. A further cause f ketsis, less relevant t peple with diabetes, is a result f excessive alchl cnsumptin. The Natinal Health Service (NHS) describes ketsis as a ptentially serius cnditin, whereas a number f ppular diets cite ketsis as being an essential part f weight lss. Ketsis is described as being ptentially dangerus as very high level f ketnes can make the bld acidic, a state knwn as ketacidsis, which can lead t serius illness in a relatively shrt space f time. (DiabetesUK). The Typical Ketgenic Diet The typical Ketgenic Diet, called the lng-chain triglyceride diet, typically prvides 3 t 4 grams f fat fr every 1 gram f carbhydrate and prtein. April 2017 Page 2

A dctr r Registered Dietitian will recmmend a daily diet that cntains 10 093 t 12 881 kj per day and 1-2 grams f prtein fr every kilgram f bdy weight. If this sunds cmplicated, it is!

3 A dctr r Registered Dietitian will recmmend a daily diet that cntains t kj per day and 1-2 grams f prtein fr every kilgram f bdy weight. If this sunds cmplicated, it is! That is why ne needs a dietitian's assistance. Picture Credit: Ketgenic Diet 2] A Ketgenic Diet Rati is the rati f fat t carbhydrate and prtein grams cmbined. A 4:1 rati is mre strict than a 3:1 rati, and is typically used fr mst children with uncntrlled epilepsy. A 3:1 rati is typically used fr infants, adlescents, and children wh require higher amunts f prtein r carbhydrate fr sme ther reasn. The kinds f fds that prvide fat fr the Ketgenic Diet are butter, heavy whipping cream, maynnaise, and ils (e.g. canla r live). Because the amunt f carbhydrate and prtein in the diet have t be restricted, it is very imprtant t prepare meals carefully. In a typical Ketgenic Diet n ther surces f carbhydrates can be eaten. The Ketgenic Diet is supervised by a Registered Dietitian wh mnitrs the child's nutritin and can teach parents and the child what can and cannt be eaten. (Anthem; Epilepsy Fundatin). The Effects f the Ketgenic Diet n the Human Bdy In essence, a ketgenic diet mimics starvatin, allwing the bdy t g int a metablic state called ketsis. Nrmally, human bdies are sugar-driven machines: ingested carbhydrates are brken dwn int glucse, which is mainly transprted and used as energy r stred as glycgen in liver and muscle tissue. When deprived f dietary carbhydrates (usually belw 50g per day), the liver becmes the sle prvider f glucse t feed ne s hungry rgans especially the brain, a particularly greedy entity accunting fr ~20% f ttal energy expenditure. The brain cannt DIRECTLY use fat fr energy. Once liver glycgen is depleted, withut a backup energy surce, humanity cannt survive. The backup is ketne bdies that the liver derives primarily frm fatty acids in the diet r bdy fat. These ketnes β-hydrxybutyrate (BHB), acetacetate and acetne are released int the bldstream, taken up by the brain and ther rgans, shuttled int the energy factry mitchndria and used up as fuel. Excess BHB and acetacetate are excreted frm urine, while acetne, due t its vlatile nature, is breathed ut (hence the characteristically sweet ket breath ). Meanwhile, bld glucse remains physilgically nrmal due t glucse derived frm certain amin acids and the breakdwn f fatty acids and s, lw bld sugar (bld glucse levels) is avided! Carbhydrate restrictin induces the pancreas t tell fat cells t release fatty acids, which get taken up by the liver and cnverted int ketnes and released int bld. Once taken up by the brain, ketnes enter the tricarbxylic acid cycle (TCA) cycle t generate energy. The TCA cycle is a series f enzyme-catalysed chemical reactins that frm a key part f aerbic respiratin in cells. This cycle is als called the Krebs cycle and the citric acid cycle. (ScientificAmerican). April 2017 Page 3

4 Ketacidsis in Breastfeeding Mm n Ketgenic Diet A Swedish mther develped a dangerus cnditin called ketacidsis as a result f a lwcarbhydrate diet (LCHF) - r Banting diet - while she was breastfeeding. In a medical reprt, published n 1 Octber 2015 in the Jurnal f Medical Case Reprts, authrs Luise vn Geijer and Magnus Ekelund discuss the case f a 32-year-ld wman wh arrived at a Swedish hspital suffering frm nausea, vmiting, heart palpitatins, trembling and extremity spasms. The wman, wh was breastfeeding her 10-mnth-ld sn, had n family histry f diabetes. She had started a strict LCHF diet (aka Banting diet), with an estimated carbhydrate intake f less than 20g per day, 10 days befre admittance, lst 4 kilgrams and had felt grwing malaise. Ketacidsis nrmally affects peple with diabetes and ccurs when sugar cannt be used by the bdy because f a lack f insulin. Fat is then used fr fuel, and acidic waste prducts called ketnes build up in the bdy. High levels f ketnes in the bdy can be very pisnus and txic. (Health24). Indicatins fr Utilising the Ketgenic Diet The Ketgenic Diet has the identified indicatins: Sme children with epilepsy that standard antiepileptic drugs cannt cntrl are candidates fr the ketgenic diet. Althugh the diet can treat several seizure types effectively, it is nt a first line treatment because it is difficult t implement and maintain, and the lng-term effects are nt well studied. Children with certain inbrn errrs f metablism such as the glucse transprter syndrme and pyruvate dehydrgenase deficiency are als candidates. A third indicatin fr utilising the Ketgenic Diet was prpsed by Buen, et al., (2013), wh fund that therwise healthy individuals n a diet with n mre than 50g carbhydrates per day, achieved bdy weight reductin with lw cardivascular risk factr management when cmpared with individuals assigned t a cnventinal lwfat diet, i.e. a restricted-energy diet with less than 30% f energy frm fat. They cncluded that the Ketgenic Diet culd be an alternative tl against besity. Sme ptential serius cmplicatins f extended utilisatin f the Ketgenic Diet may include increased chance f kidney stnes, gallbladder prblems and bne fractures, especially in children. Menstrual irregularities ften ccur in wmen, with ptential impact n fertility. There are currently insufficient studies directly mnitring the side effects f ketsis, hence it is t early t cnclude that the diet is cmpletely safe fr everyne. (Epilepsy Fundatin; ScientificAmerican). April 2017 Page 4

5 Cntraindicatins fr Utilising the Ketgenic Diet While the Ketgenic Diet ffers ptential benefits in the treatment f children with epilepsy, a paediatric neurlgist shuld carefully evaluate each child befre recmmending a trial n the ketgenic diet. Individuals n the Ketgenic Diet shuld be directly supervised by a Registered Dietitian. Medical cntraindicatins t the ketgenic diet include: metablic disrder defect in fat metablism defect in ketne metablism mitchndrial disrders β-xidatin defects primary and secndary carnitine deficiency carnitine cycle defects electrn transprt chain defects ketgenic defects ketlytic defects pyruvate carbxylate deficiency pyruvate dehydrgenase phsphatase deficiency. Thugh the diet can exacerbate kettic hypglycaemia, this cnditin is nt an abslute cntraindicatin. Sme antiepileptic drugs can ptentially exacerbate sme f the adverse effects f the ketgenic diet, and these drugs require careful use when cmbined with the diet. These antiepileptic drugs include acetazlamide, tpiramate, and znisamide, which all can cause acidsis and kidney stnes. Anther antiepileptic drug requiring careful mnitring in children n the diet is valprate. Finally, sme children and adlescents are nt candidates fr the diet because they can get their wn fd and cannt understand the restrictins f the diet. These children and adlescents will nt maintain the diet withut cnstant supervisin, which usually is nt practical. (Washingtn University in St Luis Schl f Medicine). As the Ketgenic Diet uses lipids (fats) rather than carbhydrates as the primary energy surce, it is essential that children are screened fr disrders f fat metablism, fatty acid transprtatin and xidatin, t avid metablic crisis. The abslute and relative cntraindicatins and ther pre-existing cmplicatins are listed: Abslute Cntraindicatins: Carnitine deficiency (primary) Carnitine palmityltransferase (CPT I r II) deficiency Carnitine translcase deficiency b-xidatin defects Medium-chain acyl dehydrgenase deficiency (MCAD) Lng-chain acyl dehydrgenase deficiency (LCAD) Shrt-chain acyl dehydrgenase deficiency (SCAD) Lng-chain 3-hydrxyacyl-CA deficiency Medium-chain 3-hydrxyacyl-CA deficiency. April 2017 Page 5

6 Pyruvate carbxylase deficiency Prphyria Mst f these cnditins can be excluded n a rutine urine metablic screen and bld carnitine prfile. Relative cntraindicatins: Inability t maintain adequate nutritin Surgical fcus identified by neurimaging and vide EEG mnitring Parent r caregiver hesitance re: fussy eaters, diet and nncmpliance with diet Bulbar dysfunctin r Gastr-esphageal disease -> aspiratin risk Fat micr-aspiratin fat aspiratin pneumnia -> severe cmplicatins Mst patients will require a risk assessment f aspiratin as fat-aspiratin can be lethal. Other pre-existing cmplicating factrs t be cnsidered: Presence f kidney stnes Dyslipidaemia Liver disease Failure t thrive Gastr-esphageal reflux Pr ral intake Cnstipatin Cardimypathy Chrnic metablic acidsis High carbhydrate cntent f current medicatins (Children s Epilepsy Resurces fr Clinicians). Hspital Admissin Required Children wh are treated using the Ketgenic Diet will mst likely have t stay in the hspital fr up t 2 nights and 3 days unless there are cmplicatins. It may smetimes even be necessary fr the child t stay a few days lnger. In rder fr the Ketgenic Diet t be effective, it is imprtant that yur child eats all f the fd that is prvided. The fllwing labratry tests are carried ut: Urine test fr ketnes Bld sugar levels by means f finger prick every six hurs Bld ketne levels nce a day by taking bld frm a vein Vital signs every 4 t 6 hurs bld pressure, heart rate (Seattle Children s Hspital) The Ketgenic Diet nt Suitable fr Adults The Ketgenic Diet is usually nt recmmended fr adults. Researchers at the Jhns Hpkins Epilepsy Center states that dietary therapy by means f the Ketgenic Diet has been used t treat children with epilepsy fr almst a century. Hwever, this valuable April 2017 Page 6

7 treatment ptin has nt been generally available t mst adults with seizures. Jhns Hpkins Epilepsy Center has intrduced a mdified Atkins Diet, which is a lw carbhydrate, high fat alternative t the Ketgenic Diet fr adults in Recent studies have shwn that the mdified Atkins Diet lwers seizure rates in nearly half f adults that try it, usually within a few mnths. Unlike the Ketgenic Diet (used in children), there is n hspital stay invlved, n fasting t get started, n fd weighing, and n cunting f calries r fluids. The diet is mdified frm the traditinal Atkins Diet where the intake f fats are encuraged. (Epilepsy Fundatin; Jhns Hpkins Epilepsy Center). CANSA s Psitin n the Ketgenic Diet The Cancer Assciatin f Suth Africa (CANSA) believes that the Ketgenic Diet is a treatment ptin fr children with epilepsy whse seizures are nt adequately cntrlled by means f anti-epileptic drugs (AEDs). CANSA supprts the use f the Ketgenic Diet t help t reduce the number r severity f seizures in children. CANSA accepts medical evidence that up t 70% f children with epilepsy culd have their seizures cntrlled with AEDs. Fr sme children wh cntinue t have seizures, the ketgenic diet may help. Hwever, the diet is specialised and shuld nly be carried ut under the care, supervisin and guidance f specially trained medical specialists including mnitring by a Registered Dietitian. CANSA is als f the pinin that the Ketgenic Diet shuld nt be utilised fr any ther purpse unless there is sufficient scientific evidence f its safety and efficacy Medical Disclaimer This Fact Sheet and Psitin Statement is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet and Psitin Statement. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet and Psitin Statement. Whilst the Cancer Assciatin f Suth Africa (CANSA) has taken every precautin in cmpiling this Fact Sheet and Psitin Statement, neither it, nr any cntributr(s) t this Fact Sheet and Psitin Statement can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet and Psitin Statement. April 2017 Page 7

8 Surces and References Anthem Buen, N.B., de Mel, I.S., de Oliveira, S.L. & da Rcha, A.T Very-lwcarbhydrate ketgenic diet v lw-fat diet fr lng-term weight lss: a meta-analysis f randmised cntrlled trials. Br J Nutr. Oct, 110(7): di /S Epub 2013 May 7. Children s Epilepsy Resurces fr Clinicians DiabetesUK Epilepsy Fundatin Health24 Jhns Hpkins Epilepsy Center -epilepsy-diet-center/ Ketdietapp Ketgenic Diet Ketgenic Diet 2 ScientificAmerican Washingtn University in St Luis Schl f Medicine ian/ketgenicdiet/ WebMD Wikipedia April 2017 Page 8

Cancer Association of South Africa (CANSA)

Cancer Association of South Africa (CANSA) Cancer Assciatin f Suth Africa (CANSA) Fact Sheet and Psitin Statement n Cannabis in Suth Africa Intrductin Cannabis is a drug that cmes frm Indian hemp plants such as Cannabis sativa and Cannabis indica.